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SERVICE REQUEST (SERVREO) Revised B/23/93 <br /> FACILITY IDM RECORD IUM - -- / F tj �'�+ INVOICE M <br /> t ��'Nt,`.IVs u:l �,t / <br /> M1CILI IY NAME BILLING PARTY,..�_� <br /> SITE ADDRESS ` C�1WwtL/1 r�,�G� -7 <br /> CITY J\'�,JF�c'C]v� _ - CA 21 P_"ism hov <br /> IFR/OPERATOR JCA/�!L? h-� BILLING PARTY / X <br /> ORAj 'f - ---.-..._ PHONE Mi <br /> ADPHONE <br /> DRESS (i(/-V �',� �0'rr� _ —�____ PHONE M2 <br /> CITY , ��♦t/� STATE 21P .� <br /> +ATN M Land Use Alxrl irat inn .Y � <br /> 805 Dia[ Location Code <br /> Il I <br /> 11RACTOR and/or <br /> _tVICF. REDl1ESTOR gk^ BILLING PARTY q� If / <br /> DBA !�w •_1 /� /. �_/C / PHONE M7 (��C' 45"G <br /> 'WILING ADDRESS MAO "1611 �i'fr(G(�ItlM___'�P FAX M ( <br /> CITY / STATE (7-4 — 21P <br /> 'ILLING ACKNOtILEDGEMENT: 1, the urderslgned owner, operator or agent of same, acknowledge that all alta and/or project specific <br /> IS/EMD hooly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> Sage 1 of this form. <br /> nice certify that I have prepared this sppliration and that the work to be performed witl be done to smamewall SAN <br /> -voAQ119 COUNTY Ordinance C� Standar , Siete Federal laws. <br /> 'PLICAMI'S SIGNATURE NUN 13 1436 <br /> _ SAN auAOUIN COUNTY <br /> ^ <br /> Title: l' (�k-n;L rgy __ Date:`PIy /a �. o,p!IG H ALTH SERVICES <br /> F I ENVIRONMENTAL HEALTH DIVISIPN <br /> )THOWATION TO RELEASE INrORMATION: In addition to the above, when sppiirnhle, 1, the owner, operator or agent of same, O <br /> -The property located at the above site address hereby mtthortte the role.nse of any and alt results, geotechnical data and/or <br /> mwirormental/site assessment information to SAN JOAQi1N COUNTY PUBLIC IIFALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon sa <br /> t is available and at the some time It is provided to ear or my representative. <br /> T xatwm ^ <br /> e of Service Request: Service Code r <br /> Asni <br /> rd to t )a•.Ll� , EntAnyee M 4 q I:> Date <br /> Late <br /> ate Service Ctmpl�etcd 1_T I_ / then Action Relytired: Y / N PROGRAM ELEMENT <br /> rep Amount Amotmt Poid Date of Payment Pnyment Typo Recelpt M Check M Reevd By <br /> y - ya - -- <br /> -- - PV <br /> r _ rr /_- . ,_ . .---_i ACCs ,---/ 11111T CLN <br /> CI1PV I � +y -� _/�/� <br />